How your plan works

National Coverage

www.deltadentalri.com

Delta Dental PPO Plus Premier SM

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We look forward to providing you and all of your covered family members with dental insurance. This brochure highlights your Delta Dental PPO plus Premier coverage. Please read it carefully so that you have an understanding of your dental benefits. If you would like a more detailed description, copies of your group’s Certificate of Coverage are available from the person or area in your group that handles dental benefits.

Delta Dental of Rhode Island administers your Delta Dental PPO plus Premier program and is committed to providing our members with excellent customer service. If you have any questions about your coverage, please visit our website at deltadentalri.com or call us at 1-800-843-3582.

Our website is a valuable source of dental health information. Designed especially for members, it provides you with all the information you need to manage your dental benefits with ease, including:

n Benefits & Eligibility Check your specific benefits and coverage dates

n Deductibles & Maximums Review deductible and maximum amounts, and confirm remaining balances

n Claim Status Look up the status of a claim or view your recent claim history

n ID Card Instantly print a copy of your ID Card

To begin using our online services, simply click the “Members” section from our home page. For privacy purposes, you’ll be asked to register with us before accessing our interactive features. Once you’re registered, you’ll be given a username and password that you will use each time you log in.

You can also call our easy-to-use automated information line at: 1-800-843-3582.

Our automated line is available 24 hours a day, 7 days a week. Our customer service representatives are available Monday - Thursday from 8 a.m. - 7 p.m. ET and Friday from 8 a.m. - 5 p.m. ET to answer questions or resolve problems.

Welcome to Delta Dental PPO plus Premier

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How to use Delta DentalMaximize your coverage with participating dentistsWith the Delta Dental PPO plus Premier program, you have the freedom to choose a dentist from either our PPO or Premier networks.

That’s because a participating Delta Dental dentist may belong to the PPO network, the Premier network, or both. Ask your dentist which network(s) he or she belongs to before receiving services. For services that require a coinsurance, you will have lower out-of-pocket costs with a Delta Dental PPO participating dentist.

You can view the Delta Dental PPO or Premier dentist directory by visiting our website at deltadentalri.com. You can use this online directory to check the participation status of your own dentist or to search for a new participating dentist who is conveniently located near you. Simply follow the directions to find a participating dentist in Rhode Island or in another state. When searching for a dentist outside of Rhode Island, make sure to select either the “PPO” or “Premier” dental plan. You’ll get the names and addresses of dentists in your area, plus maps and driving directions.

When you go to a participating dentist, show your identification card and discuss your treatment. After your visit, the dentist’s office will file a claim and we will pay the dentist for covered services.

If your dentist relocates or ever decides not to participate with Delta Dental, you can choose a new participating dentist from our network without any disruption in your coverage or benefits. Also, if you transfer your dental care to a non-participating dentist, you will still receive coverage for contractually covered benefits. However, you may be responsible for additional out-of-pocket expenses, such as the difference between the amount Delta Dental pays and the dentist’s actual charge.

About the Delta Dental PPO NetworkWith the Delta Dental PPO network, you can choose from more than 103,609 participating dentists in over 270,437 office locations nationwide.

About the Delta Dental Premier NetworkYou can also choose a dentist from the Delta Dental Premier network – the nation’s largest network with over 155,000 participating dentists. That’s three out of every four dentists in the country.

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Freedom to choose any dentistYou always have the option of going to a dentist who does not participate with the Delta Dental PPO or Delta Dental Premier program. However, it will usually cost you more money because the dentist hasn’t agreed to accept either the Delta Dental PPO or Delta Dental Premier allowance as full payment. You may also have to pay the dentist and file the claim yourself. You should ask the dentist to complete a standard American Dental Association (ADA) claim form. (This form is available on our website.) Claims should be sent to:

Delta Dental of Rhode IslandP.O. Box 1517Providence, RI 02901-1517

What to do in an emergencyYou are covered for procedures rendered in a dental facility by a licensed dentist, provided they are covered benefits under your plan. Delta Dental only covers services received in a dental facility; we do not cover services rendered in a hospital, surgi-center or an urgent care facility.

In the event of a life-threatening emergency, you should go to the nearest hospital for treatment and submit any claims to your medical insurance plan. Similarly, if you have an urgent dental condition, you should seek treatment at the nearest dental facility, regardless of whether the dentist participates with Delta Dental. You do not need prior approval before seeking treatment; however, your dental plan will only pay for covered benefits.

Most dental offices treat patients within 24 hours for an urgent appointment. If you need help selecting a participating dentist, use the Find A Dentist tool on our website or call Customer Service.

Pre-treatment estimatesWhenever your dentist recommends treatment that is expected to cost $300 or more, we suggest that the dentist file a pre-treatment estimate with Delta Dental. We will review the treatment plan and let you and your dentist know, in advance, how much we will cover. For services that your dental plan does not cover at 100%, having a pre-treatment estimate lets you know what your out-of-pocket costs will be. Please refer to your benefit highlights for procedures that may require pre-treatment estimates.

Who is coveredYour plan sponsor determines eligibility requirements and type of coverage available to you. Typically, an individual membership covers only you. A standard family membership covers you, your spouse, dependent children until they turn age 19 (or age 26 depending on your plan), and handicapped dependent children over age 19, who are mentally or physically incapable of earning their own living.

If your group has purchased student coverage, please check with your plan sponsor for a full explanation of the student requirements. Your plan sponsor can answer any questions you may have regarding who is covered by your plan.

Coordination of benefitsIf you or a family member are also covered by other medical or dental plans, we will coordinate payment with them using, in most cases, standard insurance industry guidelines. This helps control the overall cost of dental insurance. You are responsible for letting the dental office know about other coverage so they can provide that information on the claim.

Your Right to AppealYou have the right to appeal any adverse benefit decision on a claim or pre-treatment estimate. We will notify you of your appeal rights whenever a claim is not paid (in whole or in part) via your Explanation of Benefits form or Pre-Treatment Estimate notice. You can also find a detailed explanation of all of your rights to appeal in the “Members” section of our website – deltadentalri.com.

Please note: Review the appeals rights carefully since you will need to file an appeal within certain timeframes.

Exclusions and LimitationsYour plan also has some exclusions and limitations that you should be familiar with before receiving dental treatment. You can find a full list of these exclusions/limitations on our website.

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Change in family status or addressChanges in your family status affect your dental coverage. Please notify your plan sponsor of a:

n Change of address

n Marriage

n Birth

n Adoption

n Death of a family member

n Divorce

Consumer disclosure informationYou may obtain a copy of our Notice of Privacy Practices, Consumer Disclosure brochure, Provider Directory or the Consumer’s Guide to Health Plans in Rhode Island by visiting our website at deltadentalri.com or by calling Customer Service at 1-800-843-3582.

Notice Of Nondiscrimination And Accessibility PolicyDelta Dental of Rhode Island does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-843-3582.

Português (Portuguese): ATENÇÃO: Se fala português, encontramse disponíveis serviços linguísticos, grátis. Ligue para 1-800-843-3582.

Delta Dental PPO Plus Premier: The "dual" network advantage

Delta Dental of Rhode Island www.deltadentalri.com | 10 Charles Street | Providence, RI 02904 | 800.598.6684

Under your Delta Dental PPO Plus Premier dental program, you have the freedom to choose a dentist from either our nationwide “PPO” or “Premier” networks. That’s because a participating Delta Dental dentist may belong to the PPO network, the Premier network, or both.

For services that require a coinsurance, however, you’ll have lower out-of-pocket costs when visiting a Delta Dental PPO participating dentist.

So make sure to ask your dentist which network(s) he or she belongs to before receiving services.

Delta Dental PPO Network Network of more than 80,000 dentists practicing in over 166,000 dental locations nationwide.

Delta Dental Premier Network The nation’s largest network - with more than 139,000 dentists and over 248,000 office locations. That’s three out of every four dentists in the country.

This unique “dual” network program lets you choose a PPO network dentist for optimal cost savings, or access the larger Premier network as a secondary safety net.

Delta Dental Network Advantages

No matter whether you choose a participating PPO or Premier dentist, you’ll still enjoy all our trademark network advantages, including:

• Instant recognition of your Delta Dental ID card - nationwide • No paperwork, no hassles – network dentists will file claims directly with us on your behalf • Access to the nation’s largest dental networks

Find a Participating Dentist

To find a participating dentist – or to see if your dentist belongs to the Delta Dental network – log on to our website at www.deltadentalri.com.

You can also visit our website to access your personal benefit and eligibility information or print a copy of your ID card.

You Pay You Pay

Diagnostic

Oral Exam 0% 0% Once per calendar year

Bitewing x-rays 0% 0% One set per calendar year

Complete x-ray series or panoramic film 0% 0% Once every 36 months

Single x-rays 0% 0% As required

Preventive

Cleaning 0% 0% Twice per calendar year.

Fluoride treatment 0% 0% For children under age 19, twice per calendar year

Sealants 0% 0% For children under age 14, once every 24 months on unrestored permanent molars

Space Maintainers 20% 0% Once every 60 months for lost deciduous (baby) teeth

Minor Restorative

Fillings 20% 0% Amalgam (silver) fillings and composite (white) fillings

Repairs to existing partial or complete dentures 20% 0% Once per calendar year

Recementing crowns or bridges 20% 0% Once every 60 months

Rebasing or relining of partial or complete dentures 20% 0% Once every 60 months

Major Restorative

Crowns over natural teeth, build ups, posts and cores 40% 20% Replacement limited to once every 60 months

Endodontics

Root canal therapy on permanent teeth 20% 0% One procedure per tooth per lifetime. Vital pulpotomy and apicoectomies also covered once per tooth per lifetime.

Periodontics

Periodontal maintenance following active therapy 40% 20% Two per calendar year

Root planing and scaling 40% 20% Once per quadrant every 24 months

Osseous (bone) surgery 40% 20% Once per quadrant every 36 months (bone grafts are not included)

Gingivectomies 40% 20% Once per site every 36 months

Soft tissue grafts 40% 20% Once per site every 60 months

Crown lengthening 40% 20% Once per site every 60 months

Prosthodontics

Bridges and crowns over implants 50% 40% Replacement limited to once every 60 months

Partial and complete dentures 50% 40% Replacement limited to once every 60 months

Extractions and Oral Surgery

Extractions and other routine oral surgery 20% 0% When not covered by a patient's medical plan

Surgical placement of endosteal implant and abutment

50% 40% One per tooth site per lifetime

Orthodontics

Elective braces and related services N/A 50% For dependent children under the age of 19. Subject to a lifetime maximum. No pre-approval required.

Other Services

Palliative treatment (minor procedures necessary to relieve acute pain)

20% 0% Twice per calendar year

General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures

20% 0%

Annual Deductible: Basic: $50 Individual / $150 Family Premier: N/A

Calendar Year Maximum: Basic: $1,500 Premier: $2,000

Orthodontic Lifetime Maximum: Basic: N/A Premier: $1,500

Dependent coverage: Dependent children are covered up until the end of the month that they turn age 26.

Procedure Basic Premier Frequency / Limitations

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P

P

PPPP

PP

P

Pre-treatment Estimate recommended

AAA Northeast Delta Dental PPO Plus Premier SM

Plan Type: National Coverage

Deductible appliesD

D

DDDD

D

D

DDDDDD

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Please Note: Exams, cleanings, bitewing x-rays, single x-rays, fluorides, sealants, and full mouth/panorex x-rays do not count against your annual maximum.

n Services that are not dentally necessary and appropriate according to our review guidelines. Services subject to these guidelines include, but are not limited to, root canals; crowns and related services; bridges; periodontal services; orthodontics; and oral surgery. We will make a decision whether a service is dentally necessary based on these guidelines. A service may not be covered under these guidelines even if it was recommended by a dentist. Our guidelines can be found on our website at www.deltadentalri.com. You can have your dentist send us a request for a pre-treatment estimate in advance of the service to see if the service meets our guidelines.

n Services greater than the annual maximum.

n Services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group.

n An illness or injury that Delta Dental decides is employment-related.

n Services you would not have to pay for if you did not have this Delta Dental coverage.

n Services or supplies that are experimental in terms of generally accepted dental standards.

n Services done by a dentist who is a member of your immediate family.

n An illness, injury or dental condition for which benefits are, or would have been available, through a government program if you did not have this Delta Dental coverage.

n Services done by someone who is not a licensed dentist or a licensed hygienist working as authorized by applicable law.

n Disorders related to the temporomandibular joints (TMJ), including occlusal orthotic device and surgery.

n Services to increase the height of teeth or restore occlusion.

n Restorations needed because of teeth grinding or due to erosion, abrasion or attrition.

n Services done mainly to change or to improve your appearance.

n Splinting and other services to stabilize teeth.

n Laboratory or bacteriological tests or reports.

n Temporary, complete dentures or temporary, fixed bridges or crowns.

n Prescription drugs.

n General anesthesia or intravenous sedation for non-surgical extractions, diagnostic, preventive, or minor restorative services.

n General anesthesia or intravenous sedation given by anyone other than a dentist.

Delta Dental can adopt; and, apply, policies that we deem reasonable when we approve the eligibility of subscribers; and, the appropriateness of treatment plans and related charges.

Unless specifically covered by your dental plan, the following are not covered:

All claims must be filed within one year of the date of service.

This is a summary of benefits. The information shown here is not a guarantee of payment. Refer to the Summary Plan Description (SPD) for the full plan terms. The SPD includes any limitations or exclusions not seen here. To be covered, services must be dentally necessary and appropriate as per our review guidelines.

Time limits on services (e.g. 6, 12, 24, 36, or 60 months) are figured to the exact day. Services are then covered the following day. For example, when a service is covered once every 12 months, if the service was done on July 1, it will not be covered again until the following year on July 2 or after.

AAA Northeast Delta Dental PPO Plus Premier SM

NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY POLICY Delta Dental of Rhode Island does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-843-3582.

Português (Portuguese): ATENÇÃO: Se fala português, encontramse disponíveis serviços linguísticos, grátis. Ligue para 1-800-843-3582. REV09/18 MM/YY - QTY [BUG]

Delta Dental of Rhode Island n 10 Charles Street, Providence RI 02904 n 1.800.843.3582 n deltadentalri.com